SYSTEMATIC APPRAISAL OF NUTRITIONAL SUPPORT IN PATIENTS UNDERGOING PANCREATICODUODENECTOMY

Abstract

Introduction: Pancreaticoduodenectomy (PD) represents a distinct surgical procedure in terms of resumption of post-operative feeding: the retention of the stomach or part of the stomach combined with loss of the intestinal pacemaker cells of Cahal is known to result in alteration of gastrointestinal motility. The aim of the present study is to undertake systematic, structured appraisal of the available literature in order to identify whether consistent themes emerge and thus aid the generation of evidence-based guidelines for post-operative nutrition in patients undergoing PD. Methods: Searches of the MEDLINE and EMBASE databases for the period January 1994 to November 2004 yielded 4 studies providing discretely analyzable data on outcome in 571 patients undergoing PD. Data were retrieved on: pre-operative weight loss, biochemical parameters type and duration of nutritional support and clinical outcome. Results: The optimal route of delivery of enteral nutrition(EN) is unestablished. NJ feeding tubes may avoid the risks of surgical jejunostomy but can dislodge and can be a source of post-operative discomfort. % loss of pre-illness body weight was similar in all studies. TPN was associated with a greater risk of post-operative morbidity in all trials in which it was used. EN is associated with a lower incidence of infective complications but there was no additional benefit from I-EN. There is evidence for prolonged requirement for NG intubation in patients receiving post-operative jejunal feeding as compared to controls not receiving EN (15.1 vs 3.4 days; P < 0.01). Cyclical nutrition with periods of fasting was associated with a lower incidence of post-operative gastric stasis. Conclusions: Clear themes to emerge are that pre-operative weight loss is widespread, post-operative EN (either via NJ or jejunostomy) is the preferred route and that there is no conclusive evidence in favour of I-EN. These results can be synthesised to produce contemporary evidence-based guidelines for nutritional support in patients undergoing PD.